Health Planning with national health scenario

Health planning

1. Health Planning in India and National Policies related to Health and Health Planning

2. NATIONAL HEALTH PLANNING Health planning is an integral part of national socio-economic planning. “ the orderly process of defining community health problems , identifying unmet needs and surveying the resources to meet them, establishing priority goals that are realistic and feasible and projecting administrative action to accomplish the purpose of the proposed programme”

3. Guidelines for National Health Planning were provided by number of committees, which are appointed by Government of India to review the existing health situation and recommend measures for further action. The Goal for National Health Planning in India was to attain “Health for all by the year 2000”

4. Bhore Committee, 1946 Mudaliar Committee,1962 Chadah Committee , 1963 Mukerji Committee,1965 Mukerji Committee, 1966 Jungalwalla Committee,1967 Kartar Singh Committee,1973 Shrivastav Committee ,1975 Rural Health Scheme ,1977 Health for all by 2000 AD- Report of the working group,1981

5. BHORE COMMITTEE,1946 Sir Joseph Bhore as Chairman

6. BHORE COMMITTEE,1946 The most comprehensive health policy and plan document ever prepared in India was the ` Health Survey and Development Committee Report ’ (1943) popularly referred to as the Bhore Committee. Submitted report in 1946 (4 volumes) “ if the nation’s health is to be built, the health programme should be developed on a foundation of preventive health work and that such activities should proceed side by side with those concerned with treatment of patients .” It made comprehensive recommendations for remodelling of health services in India.

7. Objectives: The services should make adequate provision for the medical care of the individual in the curative and preventive fields and for the active promotion of positive health; These services should be placed as close to the people as possible, in order to ensure their maximum use by the community, which they are meant to serve; The health organization should provide for the widest possible basis of cooperation between the health personnel and the people; Provisions should be made for enabling the representatives of medical and auxiliary professions to influence the health policy of the country.

8. 5. “Group” practice , should be made available – In view of the complexity of modern medical practice, from the standpoint of diagnosis and treatment, consultant, laboratory and institutional facilities of a varied character, which together constitute; 6. Special provision will be required for certain sections of the population, e.g. mothers, children, elderly etc., 7. No individual should fail to secure adequate medical care, curative and preventive, because of inability to pay for it and 8. The creation and maintenance of as healthy an environment as possible in the homes of the people as well as at work.

9. Recommendations Integration of preventive and curative services of all administrative levels. 2. Major changes in medical education which includes three months training in preventive and social medicine to prepare “social physicians”.

10. Recommendations 3. Development of Primary Health Centres in 2 stages : a) Short‐term measure –One primary health centre for a 40,000 population. b) 2 doctors, 1 nurse, 4 PHN, four midwives, four trained dais, two SI, two HA, one pharmacist and 15 class IV employees. 4. A long‐term programme (also called the 3 million plan ) of setting up a) primary health units with 75 bedded hospitals for each 10,000 to 20,000 population and b) secondary units with 650 bedded hospital, again regionalised around district hospitals with 2500 beds.

11. In the fifties and sixties the entire focus of the health sector in India was to manage epidemics . Mass campaigns were started to eradicate the various diseases. These separate countrywide campaigns with a technocentric approach were launched against malaria, smallpox, tuberculosis, leprosy, filaria, trachoma and cholera. Cadres of workers were trained in each of the vertical programmes .

12. The policy of going in for mass campaigns was in continuation of the policy of colonialists who subscribed to the percepts of modern medicine that health could be looked after if the germs which were causing it were removed. But the basic cause of the various diseases is social, i.e. inadequate nutrition, clothing, and housing, and the lack of a proper environment. These were ignored .

13. National programs were launched to eradicate the diseases. The NMEP was started in 1953 with aid from the Technical Cooperation Mission of the U.S.A. and technical advice of the W.H.O. Malaria at that period was considered an international threat. The tuberculosis programme involved vaccination with BCG, T.B. clinics, and domiciliary services and after care. The emphasis however was on prevention through BCG. These programmes depended on international agencies like UNICEF, WHO and the Rockefeller Foundation for supplies of necessary chemicals and vaccines. The policy with regard to communicable diseases was dictated by the imperialist powers as in the other sectors of the economy.

14. During the first two Five Year Plans the basic structural framework of the public health care delivery system remained unchanged. Urban areas continued to get over three‐fourth of the medical care resources whereas rural areas received "special attention" under the Community Development Program (CDP). History stands in evidence to what this special attention meant. The CDP was failing even before the Second Five Year Plan began.

15. MUDALIAR COMMITTEE,1962 known as the “ Health Survey and Planning Committee ”, headed by Dr. A.L. Mudaliar . Survey the progress made since submission of Bhore report and to make further recommendations. Advised strengthening of existing PHC’s and subdivisional & district hospitals so that they function as referral centres

16. RECOMMENDATIONS 1. Consolidation of advances made in the first two 5yr plans 2. Strengthening of district hospital with specialist services 3. Regional organizations in each state for 2-3 districts. 4. PHC should not be made to cater to more than 40,000 population 5.Improve quality of health care provided by PHCs. 6.Constitution of an All India Health Service on the pattern of Indian Administrative Service.

17. CHADAH COMMITTEE,1963 This committee was appointed under chairmanship of Dr. M.S. Chadah To advise about the necessary arrangements for the maintenance phase of National Malaria Eradication Programme .

18. RECOMMENDATIONS NMEP Vigilance should be responsibility of general health services ie PHC at block level. Monthly home visits should be carried out by basic health workers (one basic health worker per 10,000 population ) These workers were also as “ multipurpose” workers to look after collection of vital statistics and family planning.

19. MUKERJI COMMITTEE,1965 The basic health workers, with their multiple functions could do justice neither to malaria work nor to family planning work . Shri Mukerji ,(Secretary of Health to the government of India) was appointed to review the strategy in the area of family planning.

20. RECOMMENDATIONS Separate staff for the family planning programme. The family planning assistants were to undertake family planning duties only. Basic Health workers for other than family planning. Delink Malaria activities from Family Planning. Accepted by Government of India.

21. MUKERJI COMMITTEE, 1966 Multiple activities of the mass programmes like family planning, small pox, leprosy, trachoma, NMEP (maintenance phase), etc. w ere making it difficult for the states to undertake these effectively because of shortage of funds . A committee of state health secretaries, headed by the Union Health Secretary, Shri Mukerji , was set up to look into this problem. Committee worked on the details of Basic Health Service to be provided at Block level and strengthening required at higher level of administration

22. JUNGALWALLA COMMITTEE,1967 This committee, known as the “Committee on Integration of Health Services ” was set up in 1964 under the chairmanship of Dr. N Jungalwalla Look into various problems related to integration of health services, abolition of private practice by doctors in government services, and the service conditions of Doctors. The committee defined “integrated health services” as :- a) A service with a unified approach for all problems instead of a segmented approach for different problems. b) Medical care and public health programmes should be put under charge of a single administrator at all levels of hierarchy.

23. RECOMMENDATIONS Integration at all service , organization and personal levels 1.Unified Cadre 2.Common Seniority 3.Recognition of extra qualifications 4. Equal pay for equal work 5. Special pay for special work 6. Abolition of private practice by government doctors 7. Improvement in their service conditions

24. KARTAR SINGH COMMITTEE,1973 This committee, headed by kartar singh was titled the “ Committee on multipurpose workers under Health and Family Planning .” a) the structure for integrated services at the periphery n supervisory levels. b) feasibility of having multipurpose workers in the field c ) training requirements for such workers d) utilization of mobile service units set up under family planning programme for integrated medical, public health and family planning services operating on field .

25. RECOMMENDATIONS Auxiliary nurse midwives replaced by female health workers(FHW). Basic health workers,vaccinators,family planning health assistants by MHWs. Multipurpose workers first introduced. 1 PHC for 50000 population.Each PHC divided into 16 sub- centres (1 for 3000-3500 people), each having 1MHW and 1FHW. Male n female health supervisors incharge of MHWs and FHWs. Doctor has overall charge of all supervisors. Introduced in 5 th Five year plan.

26. SHRIVASTAV COMMITTEE,1975 Set up in 1974 as “Group on Medical Education and Support Manpower” To determine steps to develop a curriculum for health assistants who were to function as a link between medical officers and MPWs. reorient medical education in accordance with national needs & priorities to make any other suggestions to achieve the above

27. RECOMMENDATIONS Creation of bands of paraprofessional and semiprofessional (school teachers , post masters etc.) health workers from within the community itself Establishment of 2 cadres of health workers namely – multipurpose health workers and health assistants between the community level workers and doctors at PHC. Development of a “ Referal Services Complex ” Establishment of a Medical and Health Education Commission for planning and implementing the reforms needed in health and medical education on the lines of University Grants Commission.

28. RURAL HEALTH SCHEME,1977 Launched after acceptance of shrivastav committee report. Steps were initiated Training of community health workers Involvement of medical colleges in total health care of selected PHCs and reorientation of medical education to the needs of the rural people. Reorientation training of MPWs

29. HEALTH FOR ALL BY 2000 AD-REPORT OF WORKING GROUP,1981 Constituted by planning commission in 1980 with Secretary for MOHFW as Chairman. To identify the goal for Health For All by 2000 AD To outline the specific programmes for 6 th five year plan Evolved Indices and targets to be achieved in the country by 2000AD.

30. PLANNING COMMISSION

31. Government of India has set up Planning commission in 1950 (Prime minister –Chairman) “ for assessment of material , capital and human resources of the country and to draft developmental plans for effective utilization of resources” “Perspective Planning Division”

32. Consists of Chairman , Deputy chairman and 5 members . 3 major Divisions- Programme advisors , General secretariats, Technical divisions. Planning commission has been formulating 5 years plans. reviews from time to time progress made in various directions and makes recommendations

33. Health sector Planning Planning commission gave considerable importance in Health programmes in five year plans For the purpose of planning , Health sector has been divided in to following subsections- 1.Water supply and sanitation 2. Control of communicable diseases 3.Medical education , training and research 4.Medical care –Hospitals, clinics, PHCs etc. 5.Public health services 6.Famil planning 7.Indiginous system of medicine

34. All the above subsectors were considered in five year plans based on felt needs and technical considerations. A Bureau of planning was constituted in 1965 for better coordination of central and state governments . Main function of this bureau is compilation of National Health Five year plans which is implemented at center, state, district and village level.

35. Five year plans

36. Broad objectives of health programmes during Five year plan are Control or eradication of major communicable diseases . Strengthening of Basic Health services through PHCs and Subcenters. Population control Development of Health Manpower resources

37. 1 First plan (1951-1956) 2 Second plan (1956-1961) 3 Third plan (1961-1966) 4 Fourth plan (1969-1974) 5 Fifth plan (1974-1979) 6 Sixth plan (1980-1985) 7 Seventh plan (1985-1989) 8 Period between 1989-91 9 Eighth plan (1992-1997) 10 Ninth plan (1997-2002) 11 Tenth plan (2002-2007) 12 Eleventh plan (2007-2012) 13. Twelfth five year Plan(2012-2017)

38. Twelfth Five year plan (2012-17) Health of the nation is essential component of development and economic stability. There is a strong link between Poverty and Ill health. There is need for quality Health services in remote rural areas. There is need to transform public health in to accountable, accessible ,affordable and quality services during 12 th Five year plan.

39. 12 th plan seeks to strengthen initiative taken during 11 th plan that is “Universal Health coverage ” in the country. “Ensuring equitable access for all Indian citizens ,regardless of Income level , social status, gender, Caste or Religion , to affordable, accountable and appropriate assured quality health services as well as services addressing wider determinants of health delivering to Individuals and populations, with the government being Guarantor and enabler although not necessary the only provider of Health and related services”

40. For UHC , there should be universal access to services of health and other determinants. Goal of UHC in 2 parallel steps Clinical services at different levels through public health system and supplemented by contract in private providers . Universal provision of high impact preventive and public health interventions by the Government.

41. List of Preventive and public health interventions Full Immunization for <3 years and Pregnant Full antenatal , natal and post natal care Skilled Birth attendance and Emoc facility IFA supplementation for children , adolescent and pregnant Regular treatment of Intestinal worms for children and reproductive age women Access to Iodine and Iron fortified salts Vit A supplementation (9-59 months) Access to basket of contraceptives and safe abortion services Preventive and promotive health education services Home based new born care and encouraging breast feeding.

42. List of Preventive and public health interventions 11.Community based care and referral of sick children 12. HIV testing and counselling during Antenatal care 13. Free drugs for HIV positive and PPTCT. 14. Malaria prophylaxis , LLIT bed nets , Rapid diagnostic kits and appropriate treatment. 15. School health check up s 16. Management of Diarrhea using ORS 17. Diagnosis and treatment of Tuberculosis and leprosy 18. Vaccines for Hepatitis B for high risk groups 19. Patients transport system including emergency dial 108 model .

43. Outcome Health Indicators of 12 th Five year Plan Infant mortality rate to 25/1000LBs (NFHS 5-35.2) Maternal mortality ratio to 100/1000 LBs (sample registration system-103/1000 LBs) Total Fertility rate to 2.1 (NFHS 5- 2.3 ) Prevention and reduction of undernutrition in children under 3 years to half of NFHS-3(2005-06- 58% and 46% ) levels , 27% by 2017. Prevention and reduction of anemia among women aged 15-19 years to 28%.( 59.1%-NFHS 5)

44. 6. Raising Child sex ratio in the 0-6 years age group from 914 to 950 . 7. Prevention and reduction of burden of communicable and non communicable diseases including Mental illness and injuries. 8. Reduction of poor household’s out of pocket expenditure – increase in public health spending to 1.87 % of GDP by 12 th plan. Outcome Health Indicators of 12 th Five year Plan

45. Post-2017 (No 13th Plan – new framework) Planning Commission abolished → NITI Aayog (2015) No 13th Five-Year Plan : replaced by Three-Year Action Agenda (2017–20) , Strategy for New India @75 (2018–22) , and alignment with SDGs 2030 National Health Policy 2017 : Aim: Universal Health Coverage Public health expenditure → 2.5% of GDP target Stronger focus on primary care, NCDs, equity Ayushman Bharat (2018) : Health & Wellness Centres (HWCs) for primary health care PM-JAY for secondary/tertiary care coverage Current status : IMR, MMR, TFR goals broadly achieved Undernutrition & anemia remain persistent challenges

46. 12 th five year plan goals for communicable diseases Disease 12 th plan goal Tuberculosis Reduce annual incidence and mortality to half Leprosy Reduce prevalence to <1 / 10,000 and Incidence to zero Malaria Annual Malaria incidence to less than 1/1000 Filariasis <1 percent microfilaria prevalence in all districts Dengue Sustaining case fatality rate of less than 1 percent Chikungunya Containment of out breaks Japanese encephalitis Reduction in Mortality by 30 percent Kala Azar Elimination by 2015, <1/10,000 population in all blocks HIV/AIDs Reduction of new infections to zero and comprehensive support and treatment to all cases

47. Achievements during plan period First Plan (1951-56) 12 th plan (2012-2017) 1. PHCS 725 25,650 2.Subcenters NA 156,231 3.Community Health centers - 5624 4. Total beds(2002) 125000 710,761 5.Medical colleges 42 476 6.Annual admissions in Medical colleges 3500 52,646 7.Dental colleges 7 313 8.Allopathic Doctors 65,000 1,041,395 9.Nurses(registered) 18,500 1,980,526 10.ANMS(Registered) 12,780 841,276 11.Health Visitors 578 55675 12.Health workers(F) in position - 220,707 13.Health workers(M) in Position - 56,163 14.Block Extension educator - 3512 15. Health Assistant (M) in Position - 12,288 16. Health Assistant female in position - 14267

48. Planning Commission dissolved on 17 th August 2014 and replaced by NITI Aayog on 15 th March 2015. Bottom to Top Approach Plan formed and advised by both state and center

49. With the Prime Minister as the Chairperson, presently NITI Aayog consists of: Vice Chairperson :  Suman Bery Ex-Officio Members :  Amit Shah ,  Rajnath Singh ,  Nirmala Sitaraman  and  Narendra Singh Tomar Special Invitees :  Nitin Gadkari ,  Piyush Goyal ,  Virendra Kumar ,  Ashwini Vaishnaw  and  Rao Inderjit Singh Full-time Members :  V. K. Saraswat  (former  DRDO  Chief), Ramesh Chand (Agriculture Expert) [19]  and Dr.   V. K. Paul  (Public Health expert) Chief Executive Officer (CEO) :  Parameswaran Iyer Governing Council : All  Chief Ministers  of States (and Delhi and Puducherry),  Lieutenant Governor  of Andaman & Nicobar Islands, and Special Invites

50. NITI Aayog Governments Premier Thick tank (Knowledge , Innovation and Communication) It was told to prepare 15 years vision, seven year strategy and three year action agenda documents. Three years action Agenda(2017-18,19 and 20) proposed specific health related goals to be achieved by 2020.

51. Specific Health related Goals by three years action agenda ,NITI Aayog. Reduce Maternal Mortality Ratio to 120/100000 LBs(2013-167) Reduce IMR to 30/1000 LBs(2013-40) Reduce under 5 Mortality rate to 38/1000 LBs(2015-48) Reduce TFR to 2.1(2.3 in 2013) Reduce Incidence of Tb to 130/100000(2015-217/100000) Reduce Incidence of Malaria(API) to less than 1/1000 in 90% of districts(74% in 2016) Eliminate Kala azar(80%-2015) and Lymphatic filariasis(87%-2015) Reduce premature mortality from CVDs, Cancer, Diabetes or COPDs by 1/4 th of NFHS 4 levels. Reduce out of pocket spending to 50% of the total health expenditure(2014- 62.4%)

52. National Health Policy 2017 Ministry of Health & Family Welfare, Govt. of India Tagline: “Health for All, All for Health”

53. Background • Previous policy: NHP 2002 • Need for update → changing disease burden, rising NCDs, health financing gaps • Global commitments → SDGs, Universal Health Coverage (UHC)

54. Vision & Goals Vision: Attain highest possible level of health & well-being for all Key Goals by 2025: • Increase life expectancy to 70 years • Reduce Total Fertility Rate (TFR) to 2.1 • Achieve Universal Health Coverage (UHC) • Reduce mortality (IMR, MMR, U5MR) • Eliminate leprosy, kala-azar, filariasis

55. Major Policy Thrusts • Strengthening primary health care – Health & Wellness Centres • Free essential drugs, diagnostics & emergency care • Focus on preventive & promotive health • Mainstreaming AYUSH • Public health management cadre • Digital health technology & surveillance

56. Financing & Implementation • Target: 2.5% of GDP on health by 2025 • Strategic purchasing from private sector • Health assurance through insurance schemes (Ayushman Bharat) • Decentralized planning → states as key implementers • Monitoring & accountability with measurable indicators

57. Health Indicators: India vs Bihar (Current & 2030 Targets) Indicator India (Current) India 2030 Target Bihar (Current) Bihar 2030 Target MMR (per 100,000) 88 ≤70 10 4 ≤70 IMR (per 1,000) 2 5 ≤25 2 3 Align with national U5MR (per 1,000) 31 ≤25 30 Align with national NMR (per 1,000) 19 ≤12 19 ≤12 TFR ≈2.0 Stabilise ≤2.1 3 Align with national Stunting (<5 yrs, %) 35.5% <25% 43% <30% Wasting (<5 yrs, %) 19.3% <12% 21% <15% Anaemia (women 15–49 yrs, %) 57% <30–40% 63.6% Reduce substantially TB incidence (per 100,000) 195 Eliminate by 2030 ≈294 Align with national Fully immunized children (9–11 mo , %) 93% ≥95% ≈95% ≥95%

58. National Policies related to Health and Health Planning

59. National Health Policy 2017 AIM- “ Inform, Clarify, strengthen and prioritize the role of government in shaping health systems in all its dimensions” -Investment in health -Organization of Health care services -Prevention of diseases and promotion of good health -Cross sectoral actions -access to technologies -developing Human resources -Encouraging Medical Pluralism -Building Knowledge base -developing better financial protection strategies -strengthening regulation and health assurance

60. Specific quantitative Goals and objectives Three broad components 1.Health status and programme impact 2. Health system performance 3.Health system strengthening

61. Health status and Programme Impact Life expectancy and Healthy Life Increase Life expectancy to 70 by 2025(67.5) Establishment of regular tracking of DALYs index as a measure of Burden of disease and its Trends by major categories by 2022. Reduction of TFR to 2.1 by 2025.

62. 2. Mortality by age /Cause Reduce Under5 mortality to 23 by 2025 and MMR to 100 by 2020. Reduce IMR to 28 by 2019 Reduce NMR to 16 and still birth rate to 16 by 2025.

63. Reduce disease prevalence or Incidence Achieve global target of 90 :90:90 for HIV/AIDS Achieve and maintain elimination status of leprosy by 2018,Kla azar by 2017, lymphatic filariasis in Endemic pockets by 2017. Achieve and maintain cure rate by >85% and reduce Incidence to reach elimination by 2025. To reduce prevalence of Blindness by 0.25/1000 by 2025 and disease burden by 1/3 rd from current levels . To reduce premature mortality from cardiovascular diseases, cancer, Diabetes or Chronic respiratory diseases by 25% by 2025

64. B. Health System Performance 1. Coverage of Health services- Increase utilization of Public health facilities by 50% (2025) Antenatal care and skilled Birth attendance to be sustained above 90%(2025) Full immunization by more than 90% by one year of age(2025) Meet need of Family planning by 90%(2025) 80% of known Diabetic and Hypertensives will maintain controlled status by 2025.

65. 2. Cross sectoral goals related to Health Relative reduction of prevalence of current Tobacco use by 15%(2020) and 30% by 2025. Reduction f 40% stunting in under5 children by 2025. Access to safe water and sanitation to all by 2020 Reduction of occupational Injury by half from current levels of 334 per lakh agricultural workers by 2020. National/state level tracking of current health behaviour . B. Health System Performance

66. C. Health system strengthening 1.Health Finance Increase health expenditure in percentage of GDP from 1.15% to 2.5% by 2025. Increase state sector health spending to >8% by 2020. Decrease in proportion of families facing catastrophic health expenditure from current levels to 25% by 2025.

67. 2. Health Infrastructure and Human resource Ensure availability of paramedics and Doctors as per IPHS norms in high priority districts by 2020. Increase community health volunteers to population ratio as per IPHS norms in high priority districts by 2025. Establish Primary and secondary care facility as per norms in high priority districts by 2025.

68. 3. Health Management Information system Ensure electronic database of information on health system components by 2020. Strengthen the Health surveillance system and establish registries for diseases of Public health importance by 2020. Establish health information architecture , exchanges , National health information network by 2025